When I was a kid growing up in England I used to play a card game called Top Trumps. I had several sets but my favourite was the 1978 Dracula set of Horror cards. The idea was to ‘trump’ your opponent and take his card (I didn’t know any girls that played it). Each character in the Dracula set had four ratings for Physical Strength, Fear Factor, Killing Power and Horror Rating. The higher the score the better and the winner was the person left with all the cards. If I had the character Cannibal at the top of my deck and called out “Horror rating 93” but my opponent was holding the Prince of Darkness (Dracula) who had a Horror rating of 96 I would lose, even if one of my other ratings was higher. Cannibal would often be trumped because he didn’t score very highly on anything.
I would like to see a ‘Health & Medical’ Top Trumps game. There would be a Top Trump card for each profession and we could carry a card around in our pockets for when we’re confronted by an opponent trying to trump us, or a client wielding a card from an opponent. The Health & Medical factors would look something like this:
- Bedside manner
- Consultation time
- Conservative management
- Pain science
Here’s how it could pan out. A new client/patient presents for their initial consultation with a Physiotherapist and explains how their personal trainer or remedial massage therapist has told them ‘such and such’ about their symptoms. At the first whiff of a challenge from an opponent the Physiotherapist whips out their ‘Physiotherapist’ Top Trump card and asks to see their opponents card. “Ah, I see your therapist’s ‘pathology’ score is only 47. You see [show my card], mine is 89! Your therapist may have a higher score for ‘consultation time’ than me, but I trump them in diagnosis. That means I’m right and they’re wrong. Your knee pain is not because of a ITB tight. Now give me that card!”
I occasionally have a hard time tolerating bullshit if I smell it wafting in my direction from an unsuspecting opponent because my own scores for ‘tolerance’ and ‘tact’ are pretty low.
The same scenario can work in reverse though. In true Top Trumps Horror edition fashion, let’s make the Physiotherapist ‘Cannibal’. The client presents having first consulted with their GP (Godzilla) or surgeon (Prince of Darkness). Unfortunately for Cannibal, the Prince of Darkness trumps us every damn time!! When you’ve played the game enough times you know which characters have the highest scores for each rating. The Prince of Darkness has ‘Credibility – 100’ and Godzilla isn’t too far behind. Cannibal may have scores in the high 80s and low 90s across the board, but there’s rarely ever a scenario when Cannibal trumps Godzilla or the Prince of Darkness.
This is how it commonly plays out. The client/patient comes in with a diagnosis from the Prince of Darkness or Godzilla and a recommendation for X, Y or Z. They tell us what’s wrong and what we need to do to help them. Sometimes we hear these stories of what they’ve been told by Godzilla or the Prince of Darkness and think to ourselves, “what!? [TF]”. We may feel like it’s ‘game on’ and have a crack at trumping them. That rarely works out very well for us. The client whips out their Top Trump card (metaphorically speaking) pointing at their Prince’s ‘medical’ and ‘pathology’ scores, with a look on their face which screams, ‘seriously, look at your score buddy; I can’t take you seriously’. Can we just move on and get started with what the Prince of Darkness says I need to do.”
The first person I saw today was a gentleman in his 70s. One of his concerns was shoulder pain that he’d been having for the past few weeks. He said he thought he’d “overdone it” with some overhead lifting which had been out of the ordinary (I’d call “bingo!” on that one), but he came in with an armful of imaging after seeing his GP. The report accompanying the shoulder images was unremarkable for someone of his age, with many of the typical (and normal) age-associated changes. He told me the GP has recommended a corticosteroid injection (there was no suggestion in the reports of anything inflammatory) and surgery if that didn’t work. I was thinking “what!? [TF]” and doing my best to maintain a poker-face.
It was the start of the day. I’d had a coffee and a good night’s sleep and so my ‘ballsy’ score was feeling pretty high. I took out my patient education folder and showed him a coloured graph showing the prevalence of all the things in his report found in pain-free shoulders of someone his age. I gave him my opinion, that I didn’t think the corticosteroid injection was necessary at this point and that surgery wouldn’t even be on my radar as an option. He seemed pretty happy to hear that as he didn’t want either.
In the game of Health & Medical Top Trumps, Cannibal rarely wins when he or she goes head-to-head with Godzilla or the Prince of Darkness. Choosing to go down that path is a risky strategy as it has the potential to backfire in both directions leaving Cannibal licking the wounds of a lost client/patient and undermining a professional relationship with a health and medical colleague.
In another case this past week, I’ve been well and truly trumped by a Prince of Darkness. The individual has a history of persistent pain. He had a successful surgical procedure several years ago and a long history of a local inflammatory condition in another body part. He fits a typical presentation of persistent pain with central sensitisation. In my opinion, his physical function and the various diagnoses he’s been given are inconsistent, which makes me question whether they’re correct (I think not). A recent flare-up lead to a surgical consultation and two more ‘clinical’ diagnoses (a clinical diagnosis is an educated best-guess) to add to the ones he’s been carrying about for several years. As ‘just’ a Physiotherapist, my clinical opinion hasn’t been sought; I’ve been overlooked as a medical provider and he has not consulted with me about it. At all. Prince of Darkess – 100 vs Cannibal – 0.
Here’s what Prof Lorimer Mosely said at the end of the video I recently shared:
“The most effective thing we can do in the clinical world so far for people with chronic pain, is explain it to them. That might sound really soft, but it’s hard to explain that when our intuition says pain in the tissues travels to the brain. What we’re trying to do is say, no no no, pain is a protective device and any credible evidence that you are in danger and in needing protecting will increase your pain. So we say to Physiotherapists, don’t tell them their discs is slipped, and they were lucky to get out of that, oh you’ve got the back of a 75 year old, come and see me three times a week you’ll be right. Don’t say that because they’re danger cues, and danger cues make the pain worse.”
Arthritis is quite common. It has a pretty typical pattern of symptoms and physical limitations. If a joint is arthritic, symptoms need to be significant and disabling for an orthopaedic surgeon to replace a joint. Prostheses also have a lifespan which is why joint replacements are delayed as much as possible to avoid the likelihood of a subsequent revision (replacement) later down the path, as those carry a higher risk of complications.
I’m not sure what the average minimum age is across orthopaedic surgeons for their patients to be considered suitable candidates for surgery, but 60 probably isn’t too far off for knees at least. My brother in-law had a hip replaced at 41 and some people have hips replaced in their 30s and even 20s, but they’re the outliers. If someone in their 40s has had persistent pain for many years, having more structural/tissue diagnoses added to the list they’ve been carrying about is likely unhelpful, particularly in the absence of a solution. With a contemporary understanding of pain as an emergent experience rather than a sensory input, that diagnosis becomes another one of the ‘danger cues’ Prof Moseley refers to. Mud sticks, and so too do the medical labels we affix to people and their symptoms. Several days ago I woke up with a new episode of back pain; I described it on a Facebook Live video that morning as feeling like it was “broken”. It clearly wasn’t and I knew that. Arthritis, bone-on-bone, degenerated, worn away… they’re all dangers cues. Besides, no otherwise fit, healthy, active 40-something wants to be told they’ve got the disease that “old people get”.
We also need to consider the value of imaging. If the suspicion of a clinical diagnosis in confirmed by imaging, then what next? If we tell a 40-something that they have an arthritic hip, it’s either bad enough to need replacing straight away, or it isn’t, in which case they’ll have to wait it out until it becomes bad enough to replace. Imaging the misery of being told that you’ve got another 10, 15, or 20 years of pain, discomfort, limited function and poor quality of life ahead of you before you’re considered a suitable candidate. That would suck.
We must also ask ourselves whether imaging will change the outcome of how a condition will be managed. If the answer is “no”, then the imaging isn’t helpful and a waste of resource. In my last post, I mentioned how unreliable imaging is, particularly with chronic pain. While writing this I saw a woman who had rolled her ankle. She also had pain along the bottom of both feet. It would be easy to come up with an unhelpful clinical diagnosis of ‘plantar fasciitis’. She had had an X-ray and been told that she had a heel spur. Naturally she linked the two together and believed her foot pain was due to the spurs. I talked about conditioning and its unhelpful effects here. If the referring clinician has a suspicion of a fracture or break in the ankle or foot, then the report only needed to have reported on that. Reporting on a heel spur is akin to commenting on someone’s hair being grey – it’s not relevant. Across the population, 38% of people have heel spurs; they are more common in women than men, and more common still in women >50yrs of age. Like grey hair, they are not associated with pain. We don’t comment about people’s grey hair; we shouldn’t be commenting about heel spurs in people with sore feet either!
In Health and Medical Top Trumps, Cannibal (the Physiotherapist) often has to refer people to their GP who has much higher scores for ‘medical’ and ‘pathology’. Perhaps that person does need to see the Prince of Darkness (surgeon) with a surgical score of 100 to replace an arthritic joint causing havoc on function and quality of life. But it must also work both ways. Cannibal the Physiotherapist may have a ‘Pain’ score of 96 and a ‘Conservative Management’ score of 97, higher than Godzilla or the Prince of Darkness.
As a student Physiotherapist on hospital rotations, staff used to talk about the Prince of Darkness’ and a “God Complex”; either the way that patients or staff treated the Prince, or vice versa. Whether we like it or not, there’s a food chain and we Physiotherapists are not at the top of it. I don’t fancy having to start kissing any Prince’s (arses) just to make friends, but it would be nice to meet a few sharks who don’t want to eat me, and who recognise that I’ve got something of value to offer which complements their skills, or perhaps is more useful for the task at hand.
To win the game of Medical and Professional Top Trumps, our aim is not to ‘trump’ our opponent. It’s not a pissing contest either. The aim of the game is for all the players to work out what ‘feature’ the client/patient needs most, then find the character with the highest score best equipped to help them.
I like to think that there are a handful of Godzillas and Dark Princes out there who don’t routinely trump the lowly Cannibal every time. If that’s to happen more frequently, we need to raise our game. If we’re to be considered a worthy opponent and suitable Health & Medical provider for the GP or Surgeon’s patients, then we need to be seen to have top scores in factors currently seen to be low; like Pain.
Who are we as a profession? By Erik Meira
Why Most People Are Wrong About Injuries and Pain by Lars Avemarie
Ps. Since writing this post on Friday, I bought two sets of Top Trumps card with DC Comic characters for my 4yr old son Aston, and he loves them 😉